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tuner <br />13665 (have 1--k—y <br />76.3.635) WO <br />AEr PUCA7DON FOR REAPPOPM7MENT TO C0TV <br />ADVISC RY ROARD/COMKMON <br />Cy 2 4, 2-0l <br />Commiss}on Reapply or <br />F Na <br />1 <br />st Name <br />Address _ <br />CityStaff f Z r <br />Home Phone Cell Phone Email <br />Employer�,O"�Ipation <br />Public Contact Information <br />The city maintains a directory of current board /commission members on the city's website. Once <br />appointed, state statute requires members to provide a telephone number, email address, or both where <br />the applicant can be reached. This is the contact information we will include in our online directory. <br />Please 'indicate which contact information you would like us to use: <br />LEI/Horne Phone Number ❑ Cell Phone Number eEmail Address <br />State briefly why you are interested in continuing to serve on the board/commission for which you are <br />seeking reappointment: <br />Attendance <br />Are you aware of the importance of regular meeting attendance including the time commitment involved <br />in preparing for meetings, and do you feel you still have the time available to be an active participant? <br />❑ Yes ❑ No <br />Conflict of Interest is defined as the participation in any activity, recommended action, or decision from <br />which the individual has or could have the potential to receive personal gain, whether it be direct or <br />indirect. Do you have any legal or equitable interest in any business, however organized, which could be <br />construed as a conflict of interest? ❑ Yes ❑ No <br />If yes, explain on a separate sheet of paper. <br />Ap licant Signature <br />ZZ <br />ate <br />Board/Commission Application Page 1 of 1 <br />